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General NPI Number Information
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NPI Number | 1801281639
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Entity Type | Organization
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Legal Business Name | JORGE REYES
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Dates
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Enumeration Date | 03/30/2015
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Last Update Date | 02/10/2016
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Provider Practice Location Address
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Address Line | 23550 LYONS AVE STE 211
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City | SANTA CLARITA
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State | CA
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Zip | 91321-2520
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Country | US
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Telephone | 661-360-6792
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Fax | 661-430-5414
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Provider Business Mailing Address
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Address Line | 25453 VIA LABRADA
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City | VALENCIA
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State | CA
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Zip | 91355-2718
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Country | US
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Telephone | 213-458-1459
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Fax | 661-430-5414
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Authorized Official
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Title or Position | OWNER
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Name | MR. JORGE REYES
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Credential | LCSW
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Telephone | 213-458-1459
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | LCS 27150
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | LCS 27150
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License Number State | CA
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